In rare penal cases, a defendant makes a claim that he or she was asleep at the time of an alleged crime. This article discusses a case of alleged sexsomnia where a man claimed that he had been asleep during a sexual encounter (rape) with a woman. The question that often arises during an investigation and in court is how complex a behaviour is someone able to perform and still be asleep? To assist the court in answering this question, forensic psychiatric experts may be appointed. But the experts were not present during the act and must therefore consider each case on the basis of the available information and existing research. This paper provides a brief overview of the research regarding sexsomnia. It will also discuss what kind of information is important to elaborate in these cases in order to clarify the premises for the experts? conclusions to the court.

Background: The aim of this study was to assess whether the use of alcohol and medicinal drugs among rescue workers as a consequence of the 22 July terrorist attack was associated with post-traumatic stress symptoms, and explore if there were differences between affiliated and unaffiliated rescue workers. Methods: Ten months after the bombing in the Oslo government district and the shooting at the youth camp on Utøya Island, a cross-sectional study of 1790 rescue and healthcare workers was conducted. The questionnaire included information on medicinal drug and alcohol use, experiences during rescue work and PTSS. Results: Few rescue workers reported alcohol (6.8% n = 119) or medicinal drug (5.5% n = 95) use as a consequence of participation in the 22 July terror attacks. Alcohol and medicinal drug use was associated with an elevated level of PTSS among the rescue workers who reported to use medicinal drugs (11.1 95% CI: 5.7–21.8) or alcohol (10.0 95% CI: 5.2–19.0) as a consequence of the terror attacks. Conclusion: The study found a low level of post-traumatic stress symptoms (PTSS) and alcohol and medicinal drug use among the rescue workers after the terror attacks in Norway on 22 July 2011. There was a strong association between both medicinal drug and alcohol use and elevated PTSS.

OBJECTIVE: The objective of the study was to investigate the relationship between physical injury (no, moderate and severe) and posttraumatic stress reactions (PTSR) at 4-5months after the attack in survivors of the terror attack at Utøya Island, Norway, 22 July 2011, adjusting for sociodemographic, psychosocial and trauma-related factors. METHODS: Overall, 325 young survivors (47% women, mean age 19.4years) were interviewed 4-5months (T1) and 14-15months (T2) after the attack. Variables concerning physical injury, PTSR (UCLA PTSD-RI scale, 0-4), peritraumatic exposure, sociodemographic and psychosocial backgrounds were measured. To evaluate the role of injury, multiple linear regression analyses were conducted. RESULTS: The physically injured (n=60) reported higher levels of PTSR than did the non-injured. The difference was statistically significant between the moderately injured (n=37, mean 1.9) and the non-injured (n=265, mean 1.5). No significant differences were found between the moderately and the severely (n=23, mean 1.8) injured. Higher levels of peritraumatic events, peritraumatic reactions and loss of close, female sex and non-Norwegian ethnicity were significantly related to higher levels of PTSR in the full regression model. CONCLUSION: Physical injury was associated with higher PTSR after the terror attack. Moderately injured survivors may, as those severely injured, exhibit high levels of PTSR, and this should be taken into account when targeting early psychosocial health care after terror.

Objective To assess whether systematic follow-up by general practitioners (GPs) of cases of deliberate self-poisoning (DSP) by their patients decreases psychiatric symptoms and suicidal behaviour compared with current practice. Design Randomised clinical trial with two parallel groups. Setting General practices in Oslo and the eastern part of Akershus County. Participants Patients aged 18–75 years admitted to hospital for DSP.We excluded patients diagnosed with psychoses, without a known GP, those not able to complete a questionnaire, and patients admitted to psychiatric in-patient care or other institutions where their GP could not follow them immediately after discharge. Intervention The GPs received a written guideline, contacted the patients and scheduled a consultation within one week after discharge, and then provided regular consultations for six months. We randomised the patients to either intervention (n = 78) or treatment as usual (n = 98). Main Outcome Measures Primary outcome measure was the Beck Scale for Suicide Ideation (SSI). Secondary outcomes were Beck Depression Inventory (BDI) and Beck Hopelessness Scale (BHS), selfreported further self-harm and treatment for DSP in a general hospital or an emergency medical agency (EMA). We assessed patients on entry to the trial and at three and six months. We collected data from interviews, self-report questionnaires, and hospital and EMA medical records. Results There were no significant differences between the groups in SSI, BDI, or BHS mean scores or change from baseline to three or six months. During follow-up, self-reported DSP was 39.5% in the intervention group vs. 15.8% in controls (P = 0.009). Readmissions to general hospitals were similar (13% in both groups (P = 0.963), while DSP episodes treated at EMAs were 17% in the intervention group and 7% in the control group (P = 0.103). Conclusion Structured follow-up by GPs after an episode of DSP had no significant effect on suicide ideation, depression or hopelessness. There was no significant difference in repeated episodes of DSP in hospitals or EMAs. However, the total number of incidents of deliberate self-harm reported by the patients was significantly higher in the intervention group. Trial registration Trial registration ClinicalTrials.gov Identifier: NCT01342809

Background: General Practitioners (GPs) play an important role in the follow-up of patients after deliberate self-poisoning (DSP). The aim was to examine whether structured follow-up by GPs increased the content of, adherence to, and satisfaction with treatment after discharge from emergency departments. Methods: This was a multicentre, randomised trial with blinded assignment. Five emergency departments and general practices in the catchment area participated. 202 patients discharged from emergency departments after DSP were assigned. The intervention was structured follow-up by the GP over a 6-month period with a minimum of five consultations, accompanied by written guidelines for the GPs with suggestions for motivating patients to follow treatment, assessing personal problems and suicidal ideation, and availability in the case of suicidal crisis. Outcome measures were data retrieved from the Register for the control and payment of reimbursements to health service providers (KUHR) and by questionnaires mailed to patients and GPs. After 3 and 6 months, the frequency and content of GP contact, and adherence to GP consultations and treatment in general were registered. Satisfaction with general treatment received and with the GP was measured by the EUROPEP scale. Results: Patients in the intervention group received significantly more consultations than the control group (mean 6.7 vs. 4.5 (p = 0.004)). The intervention group was significantly more satisfied with the time their GP took to listen to their personal problems (93.1 % vs. 59.4 % (p = 0.002)) and with the fact that the GP included them in medical decisions (87.5 % vs. 54. 8 % (p = 0.009)). The intervention group was significantly more satisfied with the treatment in general than the control group (79 % vs. 51 % (p = 0.026)). Conclusions: Guidelines and structured, enhanced follow-up by the GP after the discharge of the DSP patient increased the number of consultations and satisfaction with aftercare in general practice. Consistently with previous research, there is still a need for interventional studies

Objective Valid mortality statistics are important for healthcare planning and research. Suicides and accidents often present a challenge in the classification of the manner of death. The aim of this study was to analyse the reliability of the national suicide statistics by comparing the classification of suicide in the Scandinavian cause of death registers with a reclassification by 8 persons with different medical expertise (psychiatry, forensic pathology and public health) from each of the 3 Scandinavian countries. Methods The cause of death registers in Norway, Sweden and Denmark retrieved available information on a sample of 600 deaths in 2008 from each country. 200 were classified in the registers as suicides, 200 as accidents or undetermined and 200 as natural deaths. The reclassification comprised an assessment of the manner and cause of death as well as the level of certainty. Results In total, 81%, 88% and 90% of deaths registered as suicide in the official mortality statistics were confirmed by experts using the Swedish, Norwegian and Danish data sets, respectively. About 3% of deaths classified as accidents or natural deaths in the cause of death registers were reclassified as suicides. However, after a second reclassification based on additional information, 9% of the natural deaths and accidents were reclassified as suicides in the Norwegian data set, and 21% of the undetermined deaths were reclassified as suicides in the Swedish data set. In total, the levels of certainty of the experts were 87% of suicides in the Norwegian data set, 77% in the Swedish data set and 92% in Danish data set; the uncertainty was highest in poisoning suicides. Conclusions A high percentage of reported suicides were confirmed as being suicides. Few accidents and natural deaths were reclassified as suicides. Hence, reclassification did not increase the overall official suicide statistics of the 3 Scandinavian countries.

Presence of EtG or EtS among patients injured when driving or at work may indicate that very low BAC or residual effects of alcohol at the time of the accident may be associated with increased accident risk. The aim of this study was to assess: whether the alcohol metabolites EtG and EtS were present in a sample of patients injured when driving or injured at work, even if their blood alcohol concentration was negative; and, if EtG and EtS were present, what characterized these patients. Methods: Blood samples from patients admitted for treatment of injuries at a Norwegian emergency department were tested for alcohol, EtG and EtS. All samples were also analysed for medicinal and illicit psychoactive substances. Results: One hundred and ninety-two injured patients who were admitted <12 h after injury were included in the study. EtG or EtS were the most prevalent substances in the sample (17%), and a substantial proportion of the patients who tested negative for all other substances tested positive for EtG or EtS (8%). These patients were older than the rest of the sample and drank alcohol more often, according to their self-report. Conclusion: EtG and EtS were prevalent among patients injured when driving or injured at work, including patients negative for all other substances. EtG and EtS should be included in future case–control studies of psychoactive substance use among injured patients to investigate the possible association between residual alcohol effects and injuries.

Most studies of the prevalence of psychoactive substances in injured emergency department patients have excluded those who arrive more than 6 h after injury. This may cause a selection bias. The aim of this study was: (1) to describe the characteristics of patients who arrive more than 6 h after injury, compared to patients who arrive sooner (2) to examine whether self-report can add to the assessment of alcohol use when the patient is assessed more than 6 h after injury. Blood sample analysis and self-report data were used to assess the prevalence of psychoactive substances in injured patients admitted to an emergency department within 48 h of injury (n = 1611). Discriminant function analysis was used to assess group differences. The patients who arrived more than 6 h after injury differed significantly from those who arrived earlier in several respects. They more often screened positive for hypnotics; they were older, they were more likely to have had a fall and they were more often injured at home and at night. Self reported use of alcohol showed good consistency with blood sample screening within 6 h of injury and could therefore be used to assess alcohol use more than 6 h after injury. Patients who arrive more than 6 h after injury differ significantly from those who arrive earlier. Future studies on the prevalence of psychoactive substances in emergency departments could expand the inclusion window.

Alcohol is a significant risk factor for injuries. This study addresses 1) whether the risk of alcohol related injury increases with frequency of heavy episodic drinking (HED) in a linear fashion, and 2) whether a small group of high risk drinkers accounts for the majority of alcohol related injuries. We applied a case – control design. Cases were BAC positive injured patients (n = 534) and controls were respondents to a general population survey in Norway (n = 1947). Age and gender adjusted association between self-reported past year HED frequency and alcohol related injury risk was estimated in logistic regression models for all alcohol related injuries and for violence injuries and accident injuries separately. An increase in HED was associated with an increase in risk of alcohol related injury, resembling a linear risk function. The small fraction of high risk drinkers (6.6%) accounted for 41.6% of all alcohol related injuries, thus lending support to the validity of the prevention paradox. There is a strong relationship between frequency of heavy episodic drinking and risk of alcohol related injuries, yet the majority of alcohol related injuries are found among drinkers who are not in the high risk group.

Background The prevalence of alcohol and other psychoactive substances is high in biological specimens from injured drivers, while the prevalence of these psychoactive substances in samples from drivers in normal traffic is low. The aim of this study was to compare the prevalence of alcohol and psychoactive substances in drivers admitted to hospital for treatment of injuries after road traffic accidents with that in drivers in normal traffic, and calculate risk estimates for the substances, and combinations of substances found in both groups. Methods Injured drivers were recruited in the hospital emergency department and drivers in normal conditions were taken from the hospital catchment area in roadside tests of moving traffic. Substances found in blood samples from injured drivers and oral fluid samples from drivers in moving traffic were compared using equivalent cut off concentrations, and risk estimates were calculated using logistic regression analyses. Results In 21.9% of the injured drivers, substances were found: most commonly alcohol (11.5%) and stimulants eg. cocaine or amphetamines (9.4%). This compares to 3.2% of drivers in normal traffic where the most commonly found substances were z-hypnotics (0.9%) and benzodiazepines (0.8%). The greatest increase in risk of being injured was for alcohol combined with any other substance (OR: 231.9, 95% CI: 33.3- 1615.4, p < 0.001), for more than three psychoactive substances (OR: 38.9, 95% CI: 8.2- 185.0, p < 0.001) and for alcohol alone (OR: 36.1, 95% CI: 13.2- 98.6, p < 0.001). Single use of non-alcohol substances was not associated with increased accident risk. Conclusion The prevalence of psychoactive substances was higher among injured drivers than drivers in normal moving traffic. The risk of accident is greatly increased among drivers who tested positive for alcohol, in particular, those who had also ingested one or more psychoactive substances. Various preventive measures should be considered to curb the prevalence of driving under the influence of psychoactive substances as these drivers constitute a significant risk for other road users as well as themselves.

Studies have found a high prevalence of both alcohol and other impairing psychoactive drugs in injured patient populations. The aim of this study was to assess the prevalence of potentially impairing psychoactive substances in all patients admitted to a hospital emergency department with injuries from accidents, assault or deliberate self harm. A total of 1272 patients over 18 years of age, admitted to the hospital within 12h of injury, were included. Presence of alcohol was determined by an enzymatic method and other drugs by liquid chromatography-mass spectrometry (LC-MS) or gas chromatography-mass spectrometry (GC-MS), both highly specific analytical methods for determining recent intake. There were 510 (40%) women in the sample. Of the patients, 38% of the women and 48% of the men had a positive blood sample for psychoactive substances on admission. The most prevalent psychoactive substance was alcohol (27%) with an average concentration of 1.5g/kg. A further 21% of patients tested showed use of medicinal drugs, and 9% showed use of illicit substances. Cannabis was the most prevalent illicit drug (6.2%). Diazepam (7.4%) and zopiclone (5.3%) were the most prevalent medicinal drugs. In road traffic accidents, 25% of the car drivers had positive findings, about half of them for alcohol. Psychoactive substances were found in nearly half the patients admitted with injuries. The most common substance was alcohol. Alcohol was particularly related to violence, whereas medicinal drugs were most prevalent in accidents at home.

Kjølseth, Ildri; Ekeberg, Øivind & Steihaug, Sissel (2010). Why suicide? Elderly people who committed suicide and their experience of life in the period before their death. International psychogeriatrics.
ISSN 1041-6102.
22(2), s 209- 218 . doi:
10.1017/S1041610209990949

Bogstrand, Stig Tore; Ekeberg, Øivind; Rossow, Ingeborg & Normann, Per Trygve (2013). Alcohol, psychoactive substances and injuries in the emergency department. Series of dissertations submitted to the Faculty of Medicine, University of Oslo. 1507.